Plan Administrative Contact Name *

Name of individual who is responsible for the day-to-day operation of the 401k plan at your company.

First Name

Last Name

Name of Authorized Plan Representative *

Your Name

First Name

Last Name

Service Requested *

Please select which service(s) you would like us to assist with.

Fee Analysis & Summary Report

Comprehensive Benchmark Report

Consulting Services

Fee Negotiation Service

Committee Training or Participation

Affirmation that the individual listed above is an authorized plan representative with the authority to engage these services. *

I affirm the information provided in this form is true to the best of my knowledge and that I am authorized by the plan to engage these services.

Authorization to Release Plan Information & Data *

I authorize the release of any and all plan data to PLANALYTiQ and to speak with PLANALYTiQ regarding the plan identified above.

Acknowledgment of Engagement *

I acknowledge that I am engaging PLANALYTiQ to collect information on the plan listed above for the sole purpose of performing a review of all plan fees. I understand some plan service providers may require additional authorization documentation and agree to execute any necessary documents and to utilize electronic signature when provided.

Acknowledgment of Non-fiduciary Services *

I acknowledge that PLANALYTiQ is not a fiduciary to The Plan. These services are intended for informational purpose only and should not be considered to be legal, tax, investment or any other professional advice.

Acknowledgment of Service Fees *

I acknowledge that I understand the fees for the services I've selected.

Fees for our services are ERISA approved plan expenses that can be netted from plan assets. The fee summary report is $495. The fee for the benchmark report will be 30% of the difference between current total plan fees and the comparable benchmark fees. The plan sponsor may elect to be billed directly or if the fee can not be netted from plan assets. Consulting fees are billed at the rate of $350/hr + travel & expenses ($1000 minimum).

Fee for Service *

Please select payment method (only one)

Net fee from plan (ERISA approved expense)

Bill plan sponsor directly